We help our PBM and payer partners manage rising clinical review volumes with independent, timely, and evidence-based determinations.
Our technology-enabled process aligns each case with the right clinical expertise—supporting appropriate medication use, improving outcomes, and driving operational efficiency.
Through deeper clinical insight and streamlined review processes, we help PBMs reduce unnecessary spend, strengthen compliance, and ensure members receive the right therapy at the right time.
Each request is carefully screened for complete documentation, then evaluated by a nurse or physician against clinical guidelines and policy criteria. Our process includes prior authorization and prospective, concurrent, and retrospective reviews to ensure care is medically necessary, appropriate, and effective, with peer-to-peer consultation available when needed.
When a determination is appealed, a specialty-matched independent clinician reviews the case to ensure accuracy and fairness. Peer-to-peer discussions are available to clarify complex cases and support evidence-based outcomes.
As a fully accredited Independent Review Organization (IRO), CareReview provides final, impartial determinations once all internal appeals are complete—ensuring evidence-based decisions on medical necessity, appropriateness, and effectiveness of care.
CareReview provides advanced pharmacy reviews for complex or high-cost medications requiring focused clinical expertise. Our flexible, customizable solutions ensure appropriate use, patient safety, and cost-effective care.
Focused on appropriate use of high-cost and complex therapies.
Ensuring safety, efficacy, and regulatory compliance.
Helping payers detect misuse and strengthen compliance.
These advanced services extend our initial, appeal, and external review programs, giving clients targeted insights and scalable expertise to improve outcomes and performance.